Provider Demographics
NPI:1902108483
Name:WADE, SPENCER WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:WILLIAM
Last Name:WADE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 W 465 N
Mailing Address - Street 2:SUITE 140
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-4801
Mailing Address - Country:US
Mailing Address - Phone:433-213-9645
Mailing Address - Fax:435-213-9631
Practice Address - Street 1:565 W 465 N
Practice Address - Street 2:SUITE 140
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-4801
Practice Address - Country:US
Practice Address - Phone:433-213-9645
Practice Address - Fax:435-213-9631
Is Sole Proprietor?:No
Enumeration Date:2010-12-03
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8449495-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT8449495-1202OtherUTAH STATE DEPARTMENT OF COMMERCE